The Orchards At Three Rivers

jeopardy to resident health or safety

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

his interests. DPOA EE reported Resident #102 could not participate in traditional leisure activities due to his cognitive deficits.

When queried, DPOA EE reported Resident #102 could not work on jigsaw puzzles, read to himself, or watch television due to cognitive and visual deficits.

When informed Resident #102 was documented as attending religious services, DPOA EE reported religion was never important to Resident #102 and he never went to church a day in his life.

When further queried, DPOA EE reported she visited Resident #102 at the facility several times a week and never saw him participating in any 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 activity and needed 1:1(constant 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview, and record review, the facility failed to complete annual performance reviews for 3 Certified Nursing Assistants (CNAs) (CNA's T, X, and KK) of 3 reviewed for regular performance evaluations, resulting in the potential for unidentified CNA performance concerns, a lack of training related to staff performance review outcomes, and the potential for unmet care needs.Findings include:In an email sent to Nursing Home Administrator (NHA) A on 10/30/25 at 8:12am, annual performance reviews were requested for CNA's T, X and KK.Review of personnel files for CNA's T, X, and KK revealed no annual reviews were present for the past 12 months.

Further review of the employee files revealed all CNA's had been employed by the facility for more than 12 months.In an interview on 10/30/25 at 12:51pm, Business Office Manager (BOM) BB reported every nursing assistant should have a performance review done at least every 12 months and the evaluation should be kept in the employee file. BOM BB reviewed the employee files for CNA T, X and KK and confirmed no performance reviews completed in the last 12 months were present.In an interview on 10/30/25 at 1:27pm, BOM BB reported she spoke with NHA A regarding the lack of performance evaluations in the CNA employee files. BOM BB stated I heard it from the horse's mouth; performance evaluations were not done. BOM BB confirmed that performance reviews were important to ensure staff had the skills needed to complete their job duties.In an interview on 10/30/25 at 3:16pm, NHA A reported he was aware the CNA performance reviews had not been completed in the last 12 months. NHA A confirmed performance reviews were necessary in order to ensure staff have the necessary skills to care for residents.Review of a facility policy titled Nurse Aide Training Program with a reference date of 10/28/25 revealed: .5.

Additional training will be provided to each nurse aide based on any areas of weakness as determined in the nurse aide's performance reviews.education that is needed based on the performance appraisal will be completed within 90 days of the appraisal.

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

attention and patience.

They need activities they are interested in, and you can't expect them to sit still very often. (R102) just needs patience. He also likes to go for walks outside and around the unit.

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

but a Performance Improvement Plan (PIP) had not been implemented.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review the facility failed to ensure the medical director or their designee attended Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly, resulting in the potential for the decline in overall medical care provided and decreased 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review the facility failed to maintain an effective training program which included training in resident rights, quality assurance, infection control, compliance and ethics, and communication for all existing employees, resulting in the potential for decreased resident safety 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to implement an effective in-service training program for nurse aides that supported mandatory nurse aide attendance, tracked participation, and ensured continuing competence for 3 Certified Nurse Aides (identified as CNAs T, X, and KK) of 3 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.

Facility ID: