The Orchards at Three Rivers: Memory Care Staff Failures - MI
That aide, identified in inspection records only as CNA P, was one of six staff members found during a November 2025 complaint inspection to lack the behavioral health competencies required to care for residents with dementia and psychiatric diagnoses. The other five, CNA TT, CNA Z, CNA G, CNA UU, and RN BB, remained actively providing care throughout the facility at the time of the inspection.
A second aide, CNA E, told inspectors she had worked in memory care for years and regularly watched coworkers trigger residents into distress. Residents responded by flailing their arms and banging against things. CNA E told inspectors she had started to wonder whether those interactions explained why more residents were turning up with injuries of unknown origin.
The observation sat in the inspection report without resolution. Inspectors noted it. Nobody answered it.
CNA Z told inspectors it was not uncommon for other aides to abandon personal care tasks entirely because a resident became too upset when approached. RN GG, a registered nurse who witnessed the same pattern, told inspectors the staff members were not acting out of malice. "They simply just did not understand how to approach the resident," she said.
The facility's own assessment, dated August 1, 2025, documented that 43.5 percent of its residents had severe cognitive impairment. The same document listed dementia management, trauma-informed care, and care for residents with psychiatric diagnoses as areas the facility's training program was supposed to cover.
The Director of Nursing, identified as DON B, 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.
When inspectors requested verification of completed competencies for five staff members on November 25, DON B acknowledged that RN BB, CNA P, and CNA TT had not completed nursing competencies, including behavioral health competency, within the past 12 months. DON B said CNA Z, CNA UU, and RN BB had completed competencies within that window.
Inspectors reviewed the records. The competencies on file for CNA Z, CNA UU, and RN BB had all been completed more than 12 months ago. The Director of Nursing's account was wrong.
All six staff members were still on active schedules and working across the building.
CMS rated the violation at the minimal harm level, meaning inspectors found potential for harm rather than documented injury tied directly to the competency failures. But CNA E's comment about injuries of unknown origin did not disappear from the record simply because no formal connection was drawn. It remained there, unanswered.
CNA P, the aide who said she spends more time apologizing on the memory care hall than anywhere else, did not describe her situation as a staffing complaint or a training grievance. She described it as a daily reality: residents getting upset, and her not knowing how to stop it.
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 21, 2026 · Our methodology
The Orchards at Three Rivers in Three Rivers, MI was cited for violations during a health inspection on November 25, 2025.
The other five, CNA TT, CNA Z, CNA G, CNA UU, and RN BB, remained actively providing care throughout the facility at the time of the inspection.
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.