The Orchards At Three Rivers

Review of R102's medical chart revealed admission weight was 116.0 pounds on 9/11/25.

The only other weight taken for R102 was on 10/22/25 at 108.0 pounds. A loss of 8 pounds.

During an interview on 10/27/25 at 9:00 AM, with Guardian EE stated, I was told on Friday (10/24/25) the facility was sending (R102) to a special psychiatric hospital.

When I called that hospital, I was told they were told by the facility (R102) had not eaten in 72 hours and indicated he was not medically stable to be there, so they sent him immediately to the acute care hospital. He only weighed 101 pounds! How could the facility not know he was not eating! How could they not tell he was losing weight. I feel like they were killing him with the medications, and he was not eating or drinking.

During an interview on 10/27/25 at 10:00 AM, with NHA A who reported R102 was aggressive towards staff and Guardian EE on Thursday October 24 when Guardian came to visit. NHA A did not witness R102's alleged behaviors and was told by staff. He did not speak with R102's guardian. NHA A reported the facility's Medical Director, petitioned R102 to the psych/behavioral health hospital then from there R102 was sent to an acute care hospital.

Facility policy Behavioral Health Services, date implemented 3/4/25, revealed, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being.

Non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being.The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care.

The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists.

The Immediate Jeopardy that began on 9/16/25 was removed on 10/27/25 when the facility took the following actions to remove the immediacy: 1.

The DON obtained an order from the facility Psychiatrist/Resident's Physician to discontinue medication. 2.

Added 1:1 for safety of self and other residents due to increased aggression. 3.

The DON or designee completed a chart audit on all residents currently prescribed a antipsychotic medication to ensure an adequate indication for use and appropriate documentation was present to support use of the medication. 4. An audit of all residents who receive antipsych[TRUN

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services, DPOA EE reported religion was never important to Resident #102 and he never went to

10/30/25 at 1:13pm, Registered Nurse (RN) N reported she cared for Resident #102 several times per

support of one staff member) assistance to pursue any kind of leisure interests. RN N reported activities were important to residents with dementia because involvement provides the best quality of life and we can see the true person come out.In an interview on 10/30/25 at 1:40pm, former Social Services Director (SSD) H reported he was concerned about the quality and quantity of activities being offered to residents in the memory care unit where Resident #102 resided. SSD H reported he brought his concern to Nursing Home Administrator (NHA) A sometime in August 2025. In an interview on 10/30/25 at 2:08pm, Activity Assistant (AA) DD reported she was the primary activity staff member for Resident #102's unit. AA DD reported Resident #102 could not answer questions about his leisure preferences and she was not told what he liked. AA DD reported she would place leisure supplies in front of the resident to try to determine what he was interested in.

When queried about Resident #102's psychosocial well-being, AA DD reported Resident #102 seemed like he was suffering with a lot of emotional pain and distraught most of the time. AA DD reported Resident #102 could not participate in group activities.In an interview on 10/30/25 at 2:34pm, Activity Director (AD) CC reported she expected activity staff to document residents self-propelling their wheelchairs or looking out the window as self-guided leisure activities. AD CC confirmed these activities had been documented as activities for Resident #102 but could also be considered behaviors for him.

When further queried, AD CC confirmed the act of moving oneself or looking out a window did not meet the definition of a leisure activity. AD CC reported she was not familiar with Resident #102 and could not confirm the accuracy of his activity participation record. AD CC reported AA DD was having difficulty accurately documenting activity attendance.In an interview on 10/30/25 at 3:16pm, NHA A reported the facility had a identified a need for more individualized activities in the memory care unit on which Resident #102 resided.

When further queried, NHA A confirmed individualized activities in a memory care setting promote well-being and reduce behaviors.

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Review of The Essentials Guide to Healthcare Performance Reviews, www.hrforhealth.com , 2024, revealed The benefits of healthcare performance reviews go beyond creating a better experience for your team.the most important (benefit) is performance reviews lead to improved performance.greater productivity and better overall experience for your patients.

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make him comfortable. He was not with it.

His eyes were closed. He did not admit that a month ago.

attention and patience.

They need activities they are interested in, and you can't expect them to sit

This locked unit is too small to really go for walks on and there is not enough staff to meet the needs of dementia resident. -10/23/25 8:26 AM Guardian EE stated, I have not seen (R102) in a couple of weeks because of my schedule.

When I was at the facility the last time, he was awake, talking to me, and was good.

His ex-wife's name was [NAME]. I know there is a resident on the same unit named [NAME].

When I am visiting him and he hears the name [NAME] he becomes upset.

His ex-wife was very mean and abusive to him. I told staff that the name [NAME] is a trigger for him and asked staff if they could not say that name loudly or near (R102). At the facility he came from, there was a group of younger female residents that were mean to (R102).

They would pick on him and he would get mad. If they left him alone, he never had any problems. I don't think the staff at this facility listens to me when I tell them what triggers (R102). -10/23/25 at 1:07 PM, Guardian EE stated, I told the staff it would take (R102) a couple of weeks to adjust to their facility.

The other facility was bright, and he could go around in his wheelchair. He kept telling me it was too dark in this facility's unit.

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in accordance with accepted professional standards.

citation pertains to intake number: 2640123Based on observation, interview, and record review, the

reviewed for comprehensive/accurate medical records, resulting in inaccurate documentation and the potential for unmet needs.Findings include:Resident #102Review of an admission Record revealed Resident # 102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia with other behavioral disturbance(a type of brain disorder that causes cognitive decline due to damage to the blood vessels in the brain), adjustment disorder with mixed disturbance of emotions and conduct(maladaptive response to psychological stressor), and other sequalae of cerebral infarction (long term complications of a stroke).Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 9/17/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired.

Further review revealed Resident #102 displayed inattention, hallucinations (perceptual experiences in the absence of reality), delusions (misconceptions or beliefs contrary to reality), and behaviors that significantly interfere with the ability to participation in activities or social interactions.Review of a Care Plan for Resident #102 with a reference date of 9/17/25 revealed the following focus/goal/interventions: Focus #1.When (inaccurate nickname of Resident #102) displays aggression, a calm walk and conversation to de-escalate, offer the sensory room, use the sensory objects available to calm.will continue to support his social needs as he tolerates.In an interview on 10/30/25 at 8:21am, Durable Power of Attorney (DPOA) EE reported Resident #102 could not participate in traditional leisure activities due to his cognitive deficits. DPOA EE reported she visited Resident #102 at the facility several times a week and never saw him participating in any activities.

DPOA EE reported Resident #102 never went by the nickname listed in his care plan and addressing him by that name would only confuse him. DPOA EE reported she had no knowledge of Resident #102 participating in any kind of outing while at the facility and doing so would have required her permission.In an interview on 10/30/25 at 2:08pm, Activity Assistant (AA) DD reported Resident #102 could not participate in group activities.In an interview on 10/30/25 at 1:13pm, Registered Nurse (RN) N reported she cared for Resident #102 several times per week, and the resident almost never participated in any type of group activity.Review of an Activity Attendance Record for Resident #102 revealed the resident was documented as having attended bingo, movies, a party, a word game group, religious activities, roll and stroll, and outings.

The Activity Attendance Record reflected that Resident #102 participated in a group discussion, worked a jigsaw puzzle and was active in a 1:1 (activity in which the resident had a staff member assigned only to him) on 10/26/25.Review of a Nursing Note with a reference date of 10/24/25 at 3:26pm revealed Resident #102 was discharged to an acute care setting at this time and did not return to the facility.In an interview on 10/30/25 at 2:34pm, Activity Director (AD) CC reported she expected activity staff to document residents self-propelling their wheelchairs or looking out the window as self-guided leisure activities.

When further queried, AD CC confirmed the act of moving oneself or looking out a window did not meet the definition of a leisure activity. AD CC reported the facility did not offer community outings, but Resident #102 was documented as attending 2 outings. AD CC confirmed Resident #102 was discharged on 10/24/25 but his activity record reflected he actively participated in several activities on 10/26/25. AD CC reported AA DD had difficulty accurately documenting activity attendance for residents and likely entered the information in error.According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME].

Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care.

Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized .

Accessed from: Kindle Locations 24106-24108).

Elsevier Health Sciences.

Kindle Edition.

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decreased quality of care.Findings include:Review of a Quality Assurance and Performance

facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.Policy Explanation and Compliance Guidelines: The QAPI program includes.a written QAPI Plan.

The QAA (Quality Assessment and Assurance) Committee shall. consist of a minimum of.The Medical Director/designee.implement appropriate plans of action to correct identified quality deficiencies.regularly review and analyze data.At a minimum, the QAPI program will: address all systems of care and management practices.Considerations include, but are not limited to: Certain classes of medications, such as antipsychotics, which could identify trends.In an interview on 10/30/25 at 8:21am, Durable Power of Attorney (DPOA) EE reported she did not feel the facility provided Resident #102 with individualized dementia care even though she had provided the facility with interventions that helped reduce the resident's stress responses. DPOA EE reported the facility had recently added several psychotropic medications to Resident #102's medication list and she felt this could have been avoided if the staff had provided individualized care.In an interview on 10/30/25 at 12:57pm, Registered Nurse (RN) N reported she worked on the dementia care unit where Resident #102 resided and had observed that some staff members did not know how to provide interventions to reduce the resident's stress responses. RN N reported she mentioned her concerns to a member of the management team, but that staff member was no longer employed at the facility, and the facility had not taken action.In an interview on 10/27/25 at 12:57pm, Licensed Practical Nurse (LPN) U reported she cared for Resident #102 regularly. LPN U described Resident #102 as hard to handle, and that he could be very mean and scary. LPN U reported she was not sure what triggered Resident #102 when he became upset.In an interview on 10/29/25 at 1:40pm, former Social Worker (SW) H reported the QAPI committee did not review or analyze data or develop a plan of action when areas of concern were identified, including the quality of care and the activities program in the dementia care unit.In an interview on 10/30/25 at 1:14pm, Nursing Home Administrator (NHA) A reported he was the QAPI Coordinator for the facility, but he limited records of any ongoing data the QAPI committee reviewed and analyzed.In an email with a reference date of 10/29/25 at 2:31pm, Nursing Home Administrator (NHA) A asked if the QAPI plan was the same as the QAPI policy he had already provided to this writer.Review of a document labeled QAPI Plan provided by NHA A on 10/29/25 at 3:02pm, with a reference date of 2024, revealed Introduction The QAPI Plan of (name of facility was blank) .Vision.no information provided, Mission.no information provided, Purpose.no information provided, Guiding Principles.no information provided. In an interview on 10/30/25 at 3:16pm, Nursing Home Administrator (NHA) A reported the facility had a large turnover in within the management team since April 2025 and as a result QAPI had not been running smoothly.

When queried regarding data the QAPI committee routinely analyzed to ensure quality care, NHA A stated the necessary reports were not being generated due to the management staff turnover, including monitoring of the use of psychotropic medications. NHA A reported concerns related to the quality of care in the dementia unit had been discussed but a PIP had not been developed. NHA A then stated, We need to do a PIP on Dementia Care. NHA A reported the facility was not aware of any non-compliance related to the use of psychotropic medications until the survey that ended on 10/30/25. NHA A reported the committee was aware of deficient practice related to staff performance evaluations and staff training, but a Performance Improvement Plan (PIP) had not been implemented.

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The Orchards at Three Rivers 55378 Wilbur Rd Three Rivers, MI 49093

quarterly

designee attended Quality Assurance and Performance Improvement (QAPI) meetings at least

oversight of the implementation of resident care throughout the facility.Findings include:

Review of the facility's QAPI committee sign-in sheets revealed neither the medical director nor their designee physically or virtually attended a committee meeting from April-August 2025. In an interview on 10/30/25 at 3:16pm, Nursing Home Administrator (NHA) A reported the facility had a large turnover in within the management team since April 2025 and as a result QAPI had not been running smoothly.

NHA A reported the facility also changed Medical Directors in April and the former Medical Director did not attend QAPI as required. NHA A reported the new Medical Director was agreeable to attending but needed to have it scheduled in advance and that initially lead to them not attending the meeting as required.

Review of the facility's policy Quality Assurance Performance Improvement (QAPI) with a reference date of 6/2025 revealed Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.

Policy Explanation and Compliance Guidelines.2.

The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: a.

Consist of a minimum of.ii.

The Medical Director or his/her designee, b.

Meet at least quarterly.

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members.

which included training in resident rights, quality assurance, infection control, compliance and ethics,

for all residents who resided in the facility.Findings include:In an interview on 10/30/25 at 12:47pm, Director of Nursing (DON) B reported the facility used a computer-based training platform for staff training for a portion of the year but after the facility opted to stop using the platform/paying for the service, it was no longer able to access record of any training the staff had completed. DON B reported there was no current staff training program in place.In an interview on 10/30/25 at 1:14pm, DON B reported any training the staff completed would be recorded in their employee file.Review of employee files for CNA T, X and KK revealed no training related to the QAPI program, Infection Control, Compliance and Ethics, Communication or Resident Rights in the last 12 months.In an interview on 10/30/25 at 3:16pm, Nursing Home Administrator (NHA) A reported the facility had not been tracking staff training and was aware some staff training requirements had not been met. NHA A reported there was no Performance Improvement Plan in place to correct the lack of annual staff training.Review of a Facility Assessment with a reference date of 8/1/25 revealed Training Program Evaluation Our facility's training program includes .ongoing training for.existing staff.consistent with their expected roles. We complete an educational needs assessment and develop a curriculum and training plan based on staff need and resident characteristics.

The content at a minimum includes Effective communication, Resident rights.Infection Control.QAPI (Quality Assurance and Performance Improvement), Compliance and ethics.

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dementia care and abuse prevention.

program for nurse aides that supported mandatory nurse aide attendance, tracked participation, and

CNAs whose in-service training files were reviewed, resulting in the potential for unmet resident care needs.

Findings include:Review of a Nurse Aide Training Program policy with a reference date of 10/28/25 revealed Policy: The facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides. In an email on 10/29/25 at 3:28pm, documentation of Certified Nursing Assistant (CNA) in-service training for the last 12 months was requested for CNA T, X and KK.In an interview on 10/30/25 at 12:47pm, Director of Nursing (DON) B reported the facility had been without a staff educator and she was trying to cover the responsibilities of that role. DON B reported she was working on developing a staff training plan and had not put trainings in place at this time. DON B reported the facility previously used a computer-based system for staff training but was no longer using that platform for training and could not access any staff training records.In an interview on 10/30/25 at 12:51pm, Business Office Manager (BOM) BB reported it was her responsibility to maintain each staff member's personnel file.

BOM BB confirmed the documentation present in the personnel files for CNAs T, X and KK did not reflect the required 12 hours of annual training.In an interview on 10/30/25 at 3:16pm, Nursing Home Administrator (NHA) A reported he was aware the facility was not in compliance with providing CNAs 12 hours of training per year.

When further queried, NHA A reported the facility did not currently have a staff training plan.Review of The Importance of Continuing Education Credits in Healthcare, www.leaderstat.com, 2024, revealed: According to The Institute For Health Care Improvement, CE (continuing education) is a vehicle for spreading best practices and how to improve patient outcomes.