The Orchards at Three Rivers: Memory Care Staff Failures - MI
That admission came during a November inspection that found six staff members, including certified nursing assistants and a registered nurse, had not completed the behavioral health competency evaluations the facility's own assessment required. Some hadn't completed any nursing competencies in over a year. All six remained on active schedules and continued providing care throughout the building.
The facility's own records showed that nearly 44 percent of its residents had severe cognitive impairment. The facility assessment, dated August 1, 2025, identified dementia management, trauma-informed care, and the special needs of cognitively impaired residents as minimum training requirements. The staff working those halls had not been verified as competent to meet them.
CNA P told inspectors on November 20 that memory care was her least favorite assignment. "I say I'm sorry to residents back there more than anywhere else in the building," she said, "because they get so upset." She said she struggled to provide care without triggering residents' distress.
A colleague, CNA E, described watching other staff approach memory care residents in ways that caused them to flail their arms and bang against things. She told inspectors she had worked in memory care for years and regularly observed staff who didn't know how to approach residents there. She said she had begun to wonder whether those repeated triggering incidents explained why more residents were turning up with injuries of unknown origin.
CNA Z told inspectors that it was not uncommon for other aides to report they couldn't complete personal care for certain residents because the resident became too upset when approached. She said several staff members simply did not have the skills to avoid triggering psychological stress responses.
RN GG, interviewed the night of November 19, said she had witnessed staff approaching residents in ways that led to unnecessary emotional distress. She was careful to say the staff were not acting maliciously. "They simply just did not understand how to approach the resident," she told inspectors.
When inspectors requested verification of completed competencies for five staff members on November 25, the Director of Nursing, identified in the report as DON B, confirmed that RN BB, CNA P, and CNA TT had not completed nursing competencies in the last twelve months, including the behavioral health component. DON B initially reported that CNA Z, CNA UU, and RN BB had completed competencies within the required window. A review of the actual records told a different story: the evaluations on file for those three staff members were completed more than twelve months ago as well.
Six staff. Zero current behavioral health competencies. The Director of Nursing had told inspectors that staff were expected to have the skills needed to work in any area of the facility at any time, including memory care.
The inspection was classified as a complaint investigation. The level of harm was cited as minimal harm or potential for actual harm. The finding covered the failure to ensure staff had the skills to support residents' psychosocial wellbeing, to respond appropriately to residents in psychological distress, and to meet residents' care needs without triggering the responses that CNA E described watching, over and over, from the hallway.
What she couldn't say was how many of the injuries of unknown origin were connected to those encounters. The inspection report didn't answer that question either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Three Rivers from 2025-11-25 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
The Orchards at Three Rivers in Three Rivers, MI was cited for violations during a health inspection on November 25, 2025.
Some hadn't completed any nursing competencies in over a year.
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.