The Orchards at Three Rivers: Falsified Activity Records - MI
None of it was true. And two entries were logged for dates after he had already been hospitalized and never came back.
The resident, identified in inspection records only as Resident #102, was admitted to The Orchards with vascular dementia with behavioral disturbance, adjustment disorder, and long-term complications from a stroke. A formal cognitive assessment conducted in September 2025 gave him a score of 3 out of 15, placing him in the range of severe cognitive impairment. His records noted hallucinations, delusions, and behaviors significant enough to interfere with any participation in group activities or social interaction.
His power of attorney, identified in the inspection as DPOA EE, visited him several times a week. She told inspectors she never once saw him participating in any activities during those visits.
She also told them something else. The care plan listed a nickname for Resident #102, a name he had apparently never gone by. DPOA EE said addressing him by that name would only confuse him. She had no idea where the nickname came from.
The Activity Assistant responsible for his records, identified as AA DD, told inspectors Resident #102 could not participate in group activities. The registered nurse who cared for him several times per week said the same thing: he almost never participated in any type of group activity. The activity records told a completely different story.
Among the documented activities were two community outings. The Activity Director, identified as AD CC, confirmed to inspectors that The Orchards did not offer community outings. She confirmed them anyway, right there in the records.
Resident #102 was discharged to an acute care hospital on October 24, 2025. He did not return. His activity record showed him actively participating in a group discussion, completing a jigsaw puzzle, and engaging in a one-on-one activity session on October 26, two days after he had left.
When inspectors pressed AD CC on this, she acknowledged that AA DD had difficulty accurately documenting activity attendance and said the entries were likely entered in error. She also acknowledged, when asked directly, that recording a resident as self-propelling a wheelchair or looking out a window did not meet the definition of a leisure activity, despite confirming that her staff had been instructed to document exactly those things as self-guided leisure participation.
The inspection, conducted October 30, 2025, was triggered by a complaint. Inspectors cited the facility for failing to maintain a complete and accurate medical record, noting the falsified activity documentation and the care plan's use of a name the resident didn't recognize as his own.
The harm level was listed as minimal, or potential for actual harm. That classification reflects the regulatory framework's narrowest tier of concern. What it doesn't capture is what the records concealed: a man with a BIMS score of 3, unable to engage with the world around him in any meaningful way, being logged as playing bingo and attending parties while staff who cared for him regularly said he almost never left his room for group activities.
His power of attorney had no knowledge of him ever going on an outing. Any such outing, she said, would have required her permission. Nobody had asked.
DPOA EE was still visiting him several times a week when the inspection took place. She told inspectors what she saw. The activity records said something else entirely.
Resident #102 was already gone by then, transferred to a hospital six days before inspectors arrived. His records, still on file at the facility, showed him active and engaged two days after he left.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
The Orchards at Three Rivers in Three Rivers, MI was cited for violations during a health inspection on October 30, 2025.
And two entries were logged for dates after he had already been hospitalized and never came back.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.