CNA P told inspectors in November that working in the memory care unit was her least favorite assignment at The Orchards at Three Rivers. She struggled to successfully care for several residents there, she said, because she lacked the skills to avoid upsetting them.
Federal inspectors found six staff members at the facility failed to receive proper behavioral health training despite caring for residents with severe cognitive impairment. The facility's own assessment shows 43.5 percent of residents have severely impaired cognition.
CNA E, who has worked in memory care for many years, regularly witnessed other staff members triggering residents' stress responses. She described residents responding by flailing their arms and banging against things. She wondered if that explained why more residents were being found with injuries of unknown origin.
The pattern repeated throughout the memory care unit. CNA Z reported it was not uncommon for other nursing assistants to say they couldn't complete personal care for certain residents because the residents became too upset when approached.
Several staff members simply didn't have the skills needed to avoid triggering psychological stress responses, CNA Z told inspectors.
Registered Nurse GG witnessed staff approaching residents in ways that led to unnecessary emotional distress. The staff members weren't acting maliciously, she explained to inspectors. They just didn't understand how to approach the residents properly.
When inspectors asked Director of Nursing B about staff competencies, she said staff were expected to have the skills needed to work successfully in any area of the facility at any time, including the memory care unit.
But records told a different story.
Three staff members — RN BB, CNA P, and CNA TT — had not completed nursing competencies in the last 12 months, including behavioral health competency. Director of Nursing B initially told inspectors that CNA Z, CNA UU and RN BB had completed their competencies within the required timeframe.
The competency records proved otherwise. All three had completed their nursing competencies more than 12 months ago, not within the required annual period.
All six staff members remained actively employed at the facility and continued providing care throughout the building during the inspection, according to staffing schedules reviewed by inspectors.
The facility's own assessment from August acknowledged the scope of residents needing specialized care. Beyond the 43.5 percent with severely impaired cognition, the facility identified that it provides care for individuals with trauma and post-traumatic stress disorder, along with other psychiatric diagnoses.
The assessment outlined training requirements that include dementia management, caring for cognitively impaired residents, and trauma-informed care. The facility stated it develops curriculum and training plans based on staff needs and resident characteristics.
Yet the reality on the memory care unit contradicted these stated policies. Staff members openly admitted to inspectors they lacked the competencies needed to provide appropriate care.
The consequences played out daily in resident interactions. Instead of receiving care that supported their psychosocial wellness, residents experienced unnecessary distress from staff who didn't know how to approach them properly.
CNA P's frequent apologies to upset residents became a symbol of the broader failure. Her admission that she said sorry more in memory care than anywhere else revealed the human cost of inadequate training.
The inspection findings documented potential for inappropriate staff-to-resident interactions, staff inability to address residents in psychological distress, and unmet care needs that prevented residents from maintaining their highest practical psychosocial wellbeing.
For residents with severe cognitive impairment requiring specialized dementia care, the lack of properly trained staff created a cycle of distress. Staff approached residents in ways that triggered stress responses, residents reacted with physical agitation, and staff withdrew from providing needed care rather than learning appropriate techniques.
The facility assessment had identified trauma-informed care as part of its training curriculum, recognizing that many residents carried histories requiring sensitive approaches. But the gap between policy and practice left vulnerable residents in the hands of well-intentioned but inadequately prepared caregivers.
CNA E's observation about the connection between improper approaches and unexplained injuries raised additional concerns about resident safety beyond psychological wellbeing.
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.