Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Orchards At Big Rapids during CMS and state inspections, most recent first.
Surveyors identified multiple infection control failures, including improper disinfection of shared glucometers, incomplete cleaning of a PAP device, lack of gown use during wound care under Enhanced Barrier Precautions, and gaps in the Legionella water management program. Several LPNs used germicidal wipes on glucometers for far less than the required 2‑minute contact time, dried the devices immediately, or used alcohol pads instead of the manufacturer‑approved disinfectant, and one LPN carried the glucometer in a scrub pocket. A resident with chronic respiratory failure and sleep apnea had a BiPAP machine documented as cleaned daily, but the responsible LPN reported only wiping the mask and dumping the reservoir, with no cleaning of the reservoir or hose and no records of equipment checks or replacement. During wound care for this resident, an LPN did not wear a gown despite posted Enhanced Barrier Precautions signage and no gowns being available nearby. Additionally, the facility’s Legionella program lacked a completed risk identification section, a water system diagram or written description, and active flushing of plumbing lines at a former garbage disposal site where water flow was still present.
The facility failed to report an allegation of resident-on-resident abuse and a reasonable suspicion of a crime to law enforcement as required. A cognitively impaired resident entered another resident’s room, after which the second, cognitively intact resident later admitted to staff that she had pushed the first resident out of her room. The pushed resident was subsequently found with a skin tear on the upper arm and bruising on the upper back, with no prior documented skin issues or recent falls. The facility’s investigation concluded a probable unobserved physical interaction occurred, yet the NHA did not notify police and instead stated they typically only call law enforcement when they can prove a physical altercation or see certain types of injuries, contrary to the facility’s Elder Justice Act policy and state definitions of battery.
A resident with lymphedema and a right lower extremity wound did not consistently receive ordered leg pump therapy or properly monitored wound care. The lymphedema pump was often not applied as ordered, with many TAR entries marked as refusals or left blank and no documented reasons, despite the resident denying at least one recorded refusal and stating preferred treatment times. Wound care orders directed that xeroform be cut to the size of open areas, but an LPN applied full sheets over both wounds and intact skin and did not document wound appearance or review prior notes. Wound measurements and descriptions were recorded late and kept outside the EMR for several days, resulting in incomplete, delayed documentation and an inability to determine when the wound worsened.
A resident with chronic respiratory failure, CHF, sleep apnea, COPD, and other comorbidities had physician orders for nighttime BiPap with specific settings and oxygen bleed, but staff did not perform or document ongoing respiratory or BiPap assessments. The resident was observed sleeping during the day without BiPap in use, and the EMR lacked records of BiPap usage, refusals, equipment assessments, or evaluation of therapy effectiveness. The respiratory care plan referenced altered respiratory status but did not include detailed respiratory or equipment interventions, and oxygen saturation was documented only once in each of two consecutive months.
Surveyors identified that nursing staff did not maintain a medication error rate below 5 percent during observed medication passes. An LPN administered only one 500 mg tablet of metformin instead of two to a resident with diabetes, contrary to the MAR. In a separate observation, an RN administered 20 mEq of potassium instead of 40 mEq and one 100 mg capsule of gabapentin instead of two to another resident with diabetes, neuropathy, PTSD, and anxiety. These discrepancies between administered doses and MAR orders for two residents resulted in a medication error rate at or above the regulatory limit.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, potentially affecting 64 residents. Observations revealed soiled hand sinks, 3-compartment sinks, walk-in coolers, freezers, kitchen shelving, and flooring, violating the 2017 FDA Food Code.
The facility failed to follow professional standards for medication administration for two residents. Medications were left at the bedside without assessments for self-administration, contrary to facility policy. A resident with a history of cognitive impairment and another resident were both observed with medications left unattended, and no assessments were documented in their records.
The facility failed to maintain sanitary oxygen supplies for three residents, leading to deficiencies in respiratory care. Observations revealed that oxygen tubing was not properly secured in clean plastic bags for residents with respiratory conditions, despite facility policies requiring such measures. A resident's oxygen cannula was found in a garbage can, and another resident's care plan lacked directions for oxygen supply care.
The facility failed to involve resident representatives in psychotropic medication management for two residents and did not monitor necessary labs for another. A resident's representative felt pressured to consent to a GDR of Zyprexa, while another resident's Depakote dosage was increased without family involvement. Additionally, a resident on Provera for paraphilia was not monitored with required lab tests.
Inadequate Infection Control for Glucometers, PAP Equipment, Wound Care, and Legionella Prevention
Penalty
Summary
The deficiency involves multiple failures in infection prevention and control practices related to glucometer disinfection, cleaning of PAP (CPAP/BiPAP) equipment, adherence to Enhanced Barrier Precautions during wound care, and implementation of the facility’s Legionella water management program. Surveyors observed an LPN checking several residents’ blood sugars and wiping the glucometer with a germicidal wipe for only 10 seconds, then immediately drying it with gauze, despite the product label requiring a 2‑minute contact time for disinfection. The same LPN placed the glucometer in his scrub pocket between uses. Another LPN was observed cleaning a glucometer with an alcohol pad after use and stated she had been taught not to use the germicidal wipes because they were harsh on the machines, and that she always used alcohol pads instead. A third LPN reported he also used alcohol swabs after each use and stated staff were not allowed to carry glucometers in their pockets, in contrast to the observed practice. Review of the germicidal wipe label showed a required 2‑minute contact time for disinfection, and the glucometer user manual specified that the meter must be cleaned and disinfected after each patient use with approved EPA‑registered wipes, including the specific germicidal wipes stocked on the medication carts, using one wipe for cleaning and a second for disinfection. The manual did not list alcohol pads as an approved disinfectant. The DON confirmed that staff were not supposed to carry glucometers in their pockets and that nurses were supposed to use the germicidal wipes with a 2‑minute wait time, which conflicted with the observed and reported practices of the LPNs. Another deficiency concerned the cleaning of a resident’s BiPAP equipment. The resident had diagnoses including chronic respiratory failure with hypoxia, chronic diastolic congestive heart failure, sleep apnea, lymphedema, and peripheral vascular disease. Observation of the resident’s room showed the BiPAP machine on the nightstand, not in use, with no cleaning supplies present. The Treatment Assessment Record for the month directed that after the resident removed the CPAP/BiPAP in the morning, staff were to cleanse the mask and reservoir with soap and water every day shift, and the record showed all days marked as completed, including by one LPN on two specific dates. In interview, that LPN stated he cleaned only the face part of the BiPAP and dumped the water reservoir, and he was unaware there was more to cleaning the equipment; he denied cleaning the water reservoir and did not know about cleaning the hose. The NHA confirmed there were no records of when the BiPAP machine was last checked by a respiratory therapist or when the mask and hoses were replaced, and there was no indication the hose had ever been cleaned. The facility’s respiratory equipment cleaning policy did not mention CPAP or BiPAP equipment, and external educational material cited in the report stated that failure to clean PAP devices and supplies can allow bacteria and mold to grow and increase the risk of illness. Enhanced Barrier Precautions were not followed during wound care for the same resident. A sign above the resident’s bed instructed staff to use gloves and gowns during wound care under Enhanced Barrier Precautions. During a wound dressing observation, the LPN performing the care did not wear a gown and stated he did not need one because the resident did not have an infection. No gowns were visible in the resident’s room or in the hallway. In a subsequent interview, the NHA and DON confirmed that staff should be using gowns during wound care. The facility also failed to fully operationalize its Legionella prevention and water management program. In the kitchen, surveyors observed plumbing with an overhead sprayer and an open spot where garbage disposal equipment had been located, adjacent to the three‑compartment sink; the drain line was capped and water connections for the former garbage disposal were coming out of the wall. When the water management plan was requested, the facility provided the CDC toolkit document, but the section identifying buildings at increased risk was not completed, and no building water system diagram or written description was available. The dietary manager reported not having seen maintenance staff flushing the lines in the area where the garbage disposal had been removed. When asked for a written description and diagram of the water system and a Legionella Prevention Policy, the maintenance director could only provide the policy and was unable to provide the requested description or diagram. In interview, the maintenance director stated the water at the former garbage disposal site was turned off and the lines were not being flushed, but when he turned on the faucet to the overhead sprayer, a small but steady flow of water was observed, and he attributed this to hard water possibly preventing the valve from fully closing.
Failure to Report Alleged Resident-on-Resident Abuse and Suspected Crime to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and federal requirements for promptly reporting a reasonable suspicion of a crime and alleged abuse to law enforcement and other required authorities. Two residents were involved: one resident with severe cognitive impairment and dementia, and another resident with bipolar disorder, dementia, and paranoid schizophrenia who was cognitively intact. The cognitively intact resident reported that the cognitively impaired resident entered her room without permission, and she initially stated she threw a pudding cup at him. The following day, she told staff she had warned them she would hit anyone who came into her room and admitted she had pushed the other resident out of her room. Staff interviews confirmed that the cognitively impaired resident had entered the other resident’s room, but staff did not witness any physical contact. After the incident, a physical assessment of the cognitively impaired resident revealed a skin tear on the outer left upper arm above the elbow and bruising on the outer left upper back between the elbow and armpit area, with the skin tear and bruises appearing to be in line with each other. A weekly head-to-toe assessment completed six days prior documented no skin concerns and no bruises or skin tears, and incident reports showed the resident’s last fall had occurred nearly a month earlier without injury. The facility’s own investigation concluded it was probable that an unobserved physical interaction occurred between the two residents, as the cognitively intact resident acknowledged pushing the other resident out of her room. Despite the injuries and the resident’s admission that she shoved the other resident, the Nursing Home Administrator did not report the incident to law enforcement at the time it occurred. The NHA later told a responding deputy that the facility did not usually call the police unless they could prove an actual physical altercation or there was visible injury such as a bloody nose, wound, or bruising, and suggested the injured resident might have sustained the skin tear and bruises from a fall, even though records did not show a recent fall. The facility’s written policy under the Elder Justice Act required that any reasonable suspicion of a crime against a resident be reported to law enforcement and the State Survey Agency within specified timeframes, and state criminal law defined battery as forceful, violent, or offensive touching. The failure to recognize and act on a reasonable suspicion of a crime and to report the allegation of abuse and potential crime to law enforcement constituted the cited deficiency.
Failure to Provide Ordered Lymphedema Therapy and Wound Care with Adequate Assessment and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatment and care for a resident with lymphedema and a right lower extremity wound, in accordance with physician orders and the resident’s preferences. The resident, who had diagnoses including chronic respiratory failure with hypoxia, chronic diastolic heart failure, sleep apnea, lymphedema, and peripheral vascular disease, reported that staff did not consistently apply her lymphedema pump and often did not have time to complete all of her care. Observation showed the lymphedema pump sitting unused on a chair in her room. Review of the electronic medical record revealed a physician order for leg pumps twice daily at 45 for 45 minutes, but the Treatment Administration Record (TAR) for the month showed numerous refusals and blank entries, indicating missed treatments. There was no documentation explaining the refusals or reasons why the treatments were not provided, and the unit manager confirmed that such explanations were absent from the record. Further interviews revealed discrepancies between documented refusals and the resident’s account. A nurse had documented that the resident refused lymphedema treatment late one evening, but the resident denied refusing and stated her preferred times for using the pumps were after lunch and between 11:00 p.m. and midnight. From the start of the month through the survey period, the resident should have received 41 lymphedema treatments but only received 18, with 21 entries marked as refused and 2 left blank, and no explanatory notes in the medical record. The unit manager acknowledged that nurses should document reasons for refusals and that no additional information was available to clarify why the treatments were not given. The facility also failed to adequately assess, monitor, and document the resident’s right lower extremity wound. During a wound treatment observation, the resident’s leg had approximately nine bright red open areas over about one-third of the front of the leg, with small areas of healthy skin between them. The LPN performing the dressing applied full and partial sheets of xeroform over the entire wound area, including over healthy skin, contrary to the written order to apply xeroform cut to the size of open areas only. The LPN stated he did not document the wound’s appearance when providing treatments or review prior wound notes. The TAR showed daily wound treatments documented as completed, with one blank day, but wound progress notes contained only a single detailed description from mid-month, entered as a late entry several days later and describing one smaller wound with multiple small open areas within a 6 cm x 8 cm area. The wound nurse confirmed that the wound had been smaller at that time and acknowledged that applying xeroform over healthy skin could cause it to open. The unit manager confirmed that staff were not documenting wound condition after each treatment and that wound measurements were kept in a separate book and entered into the EMR days later, preventing timely assessment of wound improvement or decline.
Failure to Perform Ongoing Respiratory Assessments and Document BiPap Use
Penalty
Summary
The facility failed to provide ongoing respiratory assessments and adequate documentation for the use of a BiPap machine for one resident with significant respiratory and cardiac conditions. The resident was admitted with chronic respiratory failure with hypoxia, chronic diastolic congestive heart failure, sleep apnea, lymphedema, and peripheral vascular disease, and had a physician’s order for BiPap use at night with specified settings and oxygen bleed. The unit manager reported that the resident frequently refused to use the BiPap machine and was observed sleeping intermittently during the day without the BiPap in use. Upon review of the electronic medical record, the unit manager could not locate any documentation tracking when the BiPap was used, when it was refused, or any BiPap assessments, nor was there documentation of when the BiPap machine was last assessed or its effectiveness reviewed. The resident’s respiratory care plan identified altered respiratory status and difficulty breathing related to COPD, but the listed interventions did not include respiratory assessments, equipment assessments, the level of assistance needed, or schedules for equipment replacement or evaluation of effectiveness. Oxygen assessments for the resident were documented only once in March and once in April, each time noting oxygen saturation with oxygen via nasal cannula, with no additional ongoing monitoring recorded. The nursing home administrator acknowledged an increase in residents using C-Pap and BiPap devices and confirmed that the facility did not currently have respiratory therapist services in place at the time of the survey.
Medication Administration Errors Exceeding 5 Percent Threshold
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5% during observed medication administration. For one resident with multiple diagnoses including diabetes, an LPN prepared and administered ten medications during a morning medication pass, verbally identifying each medication and dose while placing them into a medication cup. Review of the resident’s Medication Administration Record (MAR) for the month showed that this resident was ordered to receive two tablets of metformin 500 mg, but the nurse administered only one tablet. In a separate observation the same morning, an RN administered nine medications to another resident with multiple diagnoses including diabetes with diabetic neuropathy, PTSD, and anxiety. During this pass, the RN gave one tablet of potassium 20 mEq and one capsule of gabapentin 100 mg. Review of this resident’s April MAR revealed that the resident was ordered potassium 40 mEq, not 20 mEq, and two capsules of gabapentin 100 mg, not one. These observed discrepancies between the medications and doses administered and the corresponding physician orders/MAR entries for two residents resulted in a medication error rate of 5% or greater.
Deficiency in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, which could potentially affect 64 residents. During an inspection, several areas within the kitchen were found to be visibly soiled and in disrepair. The hand sink basin had a noticeable build-up of grime and scale, and the plumbing fixture was leaking. The 3-compartment sink, including its drain boards, backsplash, and basins, was also observed to be dirty with scale, grime, and debris. Additionally, the walk-in cooler and freezer had doors, handles, and other components that were visibly soiled with dust, food residues, mold, and mildew. Further observations revealed that kitchen shelving units and the flooring in the dry storage area were not properly cleaned, with residues and debris accumulation. The hallway leading to the outside dumpster area also had an accumulation of rock salt, dust, and debris. These conditions are in violation of the 2017 FDA Food Code, which mandates regular cleaning and maintenance of plumbing fixtures, warewashing equipment, and physical facilities to prevent contamination and ensure sanitary conditions.
Failure to Follow Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for two residents. Resident #1, a 69-year-old male with a history of seizure disorder, muscle weakness, cognitive communication deficit, glaucoma, and mild cognitive impairment, was observed with his morning medications left on his bedside table in a plastic cup. He indicated that he would take the medications later. A review of his electronic health record revealed that there was no assessment completed to determine his ability to self-administer medications. The facility administrator confirmed that no residents had been assessed for self-administration of medications. Similarly, Resident #17 was observed with morning medications left on the over-bed table in a plastic cup. The resident stated that medications were usually left for him to take. A review of his electronic health record also showed no assessment for self-administration. A registered nurse confirmed that leaving medications at the bedside without an assessment was not a standard practice at the facility. The facility's policy requires an interdisciplinary team assessment of a resident's ability to self-administer medications, which was not conducted for these residents.
Deficiency in Maintaining Sanitary Oxygen Supplies
Penalty
Summary
The facility failed to maintain sanitary oxygen supplies for three residents, leading to deficiencies in respiratory care. Resident #19 was observed with oxygen tubing draped over the handle of a portable oxygen tank without a clean plastic bag to secure it. This occurred despite a general administration history indicating that oxygen supplies should be changed and dated every Sunday and as needed. Resident #29, who has chronic respiratory failure and other respiratory conditions, was observed with oxygen tubing draped over a fan and additional tubing not secured in a clean plastic bag. The care plan for this resident did not include directions for staff regarding the care of oxygen supplies. Resident #115, diagnosed with conditions including COPD and heart failure, reported using oxygen only at night. Observations revealed that the resident's oxygen nasal cannula was resting in a garbage can and later on top of the oxygen concentrator, with no clean plastic bag nearby. The treatment administration history for this resident indicated that oxygen tubing should be changed weekly and as needed, but did not specify additional supply requirements or date marking. A registered nurse confirmed that oxygen tubing should be stored in a clean plastic bag changed weekly. The facility's policy on respiratory treatment and oxygen, updated in 2021, requires dating all equipment and storing oxygen supplies in a dated plastic bag when not in use.
Failure to Involve Representatives and Monitor Labs in Psychotropic Management
Penalty
Summary
The facility failed to involve resident representatives in the psychotropic medication management process for two residents and did not monitor laboratory studies for another resident. For Resident #3, the facility did not adequately involve the resident's representative in the decision-making process regarding the gradual dose reduction (GDR) of Zyprexa, despite the representative's concerns about potential negative impacts on the resident's psychosocial wellbeing. The representative felt pressured to consent to the medication change due to perceived state regulations, even though the resident was stable and not overmedicated. For Resident #45, the facility increased the dosage of Depakote without involving the resident's responsible party in the decision. The resident continued to exhibit agitated and restless behaviors, and the facility later discussed medication changes with the family, but the initial increase in Depakote was made without their input. This lack of communication and involvement of the resident's representative in medication management decisions is a significant oversight. Resident #33 was prescribed Provera for paraphilia, but the facility failed to conduct necessary laboratory tests to monitor the resident's condition and the effects of the medication. The facility physician did not order liver function tests, serum testosterone, or other relevant labs, which are required for monitoring patients on medroxyprogesterone. This lack of monitoring could potentially lead to unaddressed health issues related to the medication use.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Big Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehabilitation Of | 0.1 mi | ★★★★★ | 0 | 0 |
| Corewell Health Reed City Hospital Rehabilitation | 11.4 mi | ★★★★★ | 9 | 0 |
| Grand Oaks Nursing Center | 22.1 mi | ★★★★★ | 2 | 0 |
| Newaygo Co Medical Care Facility | 26.8 mi | ★★★★★ | 0 | 0 |
| Regency At Fremont | 26.8 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.