Federal inspectors found The Orchards at Three Rivers failed to provide meaningful activities for Resident 102, a memory care patient whose power of attorney reported he could not participate in traditional programs due to cognitive and visual deficits.
The resident's designated power of attorney told inspectors during an October 30 visit that Resident 102 could not work jigsaw puzzles, read, or watch television. When staff documented him attending religious services, the family member said religion was never important to him and "he never went to church a day in his life."
Despite visiting several times weekly, the power of attorney never observed Resident 102 participating in any activities.
Registered Nurse N, who cared for the resident multiple times per week, confirmed he "almost never participated in any type of activity" and required constant one-on-one staff support to pursue leisure interests. The nurse said activities were crucial for dementia patients because "involvement provides the best quality of life and we can see the true person come out."
Activity Assistant DD, the primary activity staff member for Resident 102's unit, described a resident in distress. She said he "seemed like he was suffering with a lot of emotional pain and distraught most of the time" and could not participate in group activities.
The assistant said Resident 102 could not answer questions about his preferences and she was never told what he enjoyed. Her approach involved placing leisure supplies in front of him to try determining his interests.
Activity Director CC revealed the problematic documentation practices. She told inspectors she expected staff to record residents "self-propelling their wheelchairs or looking out the window as self-guided leisure activities."
These actions had been documented as activities for Resident 102, though the director acknowledged they "could also be considered behaviors for him." When pressed further, she admitted that moving oneself or looking out a window "did not meet the definition of a leisure activity."
The activity director said she was unfamiliar with Resident 102 and could not confirm the accuracy of his participation records. She reported that Activity Assistant DD was having difficulty accurately documenting attendance.
Former Social Services Director H had raised concerns about activity quality and quantity in the memory care unit where Resident 102 lived. He brought these concerns to Administrator A in August 2025.
Nursing Home Administrator A acknowledged the facility had identified a need for more individualized activities in the memory care unit. She confirmed that individualized activities in memory care settings "promote well-being and reduce behaviors."
The inspection revealed a gap between what constituted actual therapeutic activities and what staff recorded as participation. While the facility counted passive behaviors like wheelchair movement and window gazing as leisure activities, the resident's family observed no meaningful engagement during regular visits.
The former social services director's concerns about memory care activities preceded the inspection by months, suggesting ongoing recognition of inadequate programming for cognitively impaired residents.
Staff acknowledged the importance of proper activities for dementia patients while simultaneously documenting non-activities as participation. The activity director's admission that wheelchair movement and window staring failed to meet leisure activity definitions highlighted the disconnect between documentation and actual care.
The resident's emotional distress, as observed by his primary activity assistant, underscored the human cost of inadequate programming. While requiring constant support to engage in any meaningful activity, Resident 102 was credited with participation he could not actually achieve.
The facility's administrator confirmed individualized activities reduce behavioral issues in memory care patients, yet the inspection found exactly the opposite occurring. A resident who appeared to suffer emotional pain was documented as participating in activities that were actually just basic movements or passive observation.
The power of attorney's consistent visits provided a stark contrast to staff documentation. Family members who spent significant time at the facility never witnessed the participation that appeared regularly in official records.
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Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Three Rivers from 2025-10-30 including all violations, facility responses, and corrective action plans.