The Orchards At Three Rivers

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes #2663418Based on interview and record review, the facility failed to operationalize its abuse policy and procedure for 1 resident (Resident #100) of 5 residents reviewed for abuse, resulting in potential abuse not being reported to the Nursing Home Administrator (NHA) immediately.Findings include:Resident #100Review of an admission Record revealed Resident #100 was originally admitted to

the facility on [DATE REDACTED] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive decline in cognitive skills), cognitive communication deficit (communication challenge caused by impaired thinking skills), and fracture of nasal bones.Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 10/29/25, revealed Resident #100 was rarely to never understood and a Brief Interview for Mental Status (BIMS) could not be conducted. Section GG revealed Resident #100 was dependent for rolling in bed and transferring from bed to wheelchair.Review of a Care Plan for Resident #100 with a reference date of 9/18/25 revealed the following focus/goal/interventions: Focus: (Resident #100) is at risk for falls/injury r/t (related to) confusion.h/o (history of) falls, places head on surfaces.intentionally bumping head against dining room table. Goal: (Resident #100) will not sustain serious injury. Interventions: fall mat to floor beside bed.padding on right assist bar on bed.when resident is sitting at table, place an activity pad on table in front of resident.In an interview on 11/17/25 at 11:48am, Registered Nurse (RN) GG reported on 9/10/25 in the morning hours, she noticed a hematoma on Resident #100's forehead, approximately 2x2, and immediately called Unit Manager (UM) U to report the injury of unknown origin. RN GG reported UM U told her the injury was from a fall the resident had approximately 3 weeks earlier. RN GG reported UM U did not come view the injury but based on the telephone conversation, assumed the injury was not new.In an interview on 11/24/25 at 3:15pm, Director of Nursing (DON) B and Nursing Home Administrator (NHA) A reported Resident #100's hematoma reported

on 9/10/25, was mistakenly thought to have been from her fall that occurred a few weeks prior. DON B and NHA A confirmed this was an injury of unknown origin that should have been reported NHA A immediately as a potential situation of resident abuse.In an interview on 11/24/25 at 2:24pm UM U reported she received a call regarding a hematoma on Resident #100's forehead but she assumed the injury was from a fall the resident had 3 weeks prior to the call on 9/10/25 and did not go assess the resident. UM U confirmed days later she saw the injury and realized it was new and should have been reported to NHA A immediately as an injury of unknown origin/potential abuse.Review of an Abuse and Neglect Prohibition policy with a reference date of 11/9/24 revealed Policy: Each resident has the right to be free from abuse, mistreatment.G. Reporting and Response: 1. The staff will report all allegations of abuse.to the Administrator immediately.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

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Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2663418Based on interview, and record review, the facility failed to report injuries of unknown origin to the State Agency in a timely manner for 1 (Resident #100) of 5 residents reviewed for abuse and reporting, resulting in the potential for ongoing mistreatment to go unrecognized.Findings include:Resident #100Review of an admission Record revealed Resident #100 was originally admitted to

the facility on [DATE REDACTED] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive decline in cognitive skills), cognitive communication deficit (communication challenge caused by impaired thinking skills), and fracture of nasal bones.Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 10/29/25, revealed Resident #100 was rarely to never understood and a Brief Interview for Mental Status (BIMS) could not be conducted. Section GG revealed Resident #100 was dependent for rolling in bed and transferring from bed to wheelchair.Review of a Care Plan for Resident #100 with a reference date of 9/18/25 revealed the following focus/goal/interventions: Focus: (Resident #100) is at risk for falls/injury r/t (related to) confusion.h/o (history of) falls, places head on surfaces.intentionally bumping head against dining room table. Goal: (Resident #100) will not sustain serious injury. Interventions: fall mat to floor beside bed.padding on right assist bar on bed.when resident is sitting at table, place an activity pad on table in front of resident.In an interview on 11/17/25 at 11:48am, Registered Nurse (RN) GG reported on 9/10/25 in the morning hours, she noticed a hematoma on Resident #100's forehead, approximately 2x2, and called Unit Manager (UM) U to report the injury of unknown origin. RN GG reported UM U told her the injury was from a fall the resident had approximately 2 weeks earlier. RN GG reported UM U did not come view the injury but based on the telephone conversation, assumed the injury was not new.In an interview on 11/17/25 at 11:50am, Certified Nursing Assistant (CNA) N reported she also saw the hematoma on Resident #100's forehead on 9/10/25. CNA N reported she regularly cared for Resident #100 and at times saw her put her forehead down on the table in

the dining room but had never seen her do with the degree of force that would be needed to cause that type of injury she had. CNA N reported the hematoma was initially fairly small on 9/10/25 but became more elevated as the day went progressed. CNA N reported she cared for Resident #100 the previous day and did not see any injuries on the resident at that time.In an interview on 11/24/25 at 3:15pm, Director of Nursing (DON) B and Nursing Home Administrator (NHA) A reported Resident #100's hematoma reported

on 9/10/25, was mistakenly thought to have been from her fall that occurred a few weeks prior. DON B and NHA A confirmed this was an injury of unknown origin that should have been reported within 24 hours to

the State Agency.Review of a Incident Report revealed Resident #100's injury of unknown origin which was first identified on 9/10/25, was reported to the State Agency on 9/15/25 at 1:44pm.Review of an Abuse and Neglect Prohibition Policy with a reference date of 11/9/24 revealed Procedure.G. Reporting and Response.3. The Administrator or designee is responsible for reporting to the State Agency ALL alleged violations .including injuries of unknown origin.b. not later than 24 hours if the events that cause the allegation do not involve abuse or serious injury.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

consistent with her falling out of bed and hitting her head. CNA Z stated I wonder if she fell and someone just picked her back up?. CNA Z reported he did not believe the injury she sustained would have happened as the result of the resident hitting her head on the table. CNA Z added that he felt some of the staff who were less familiar with the residents in memory care were struggling to properly care for them. CNA Z reported he was never interviewed about any of the recent injuries of unknown origin.In an interview on 11/24/25 at 10:21am CNA JJ reported she regularly worked on the memory care unit. When queried, CNA JJ reported NHA A did not interview her regarding any of the recent resident injuries of unknown origin.In

an interview on 11/24/25 at 3:32pm, NHA A reported the facility had 6 instances in which residents suffered injuries of unknown origin between 9/10-11/2/25. When queried regarding the investigation process for

these incidents, NHA A reported he took 5 random witness statements for the incident involving Resident #100 but did not interview any staff from the 3rd shift. NHA A reported he had no witness statements regarding the 5 remaining incidents in which residents suffered injuries of unknown origin. NHA A confirmed that the facility did not monitor staff interactions with the residents after the injuries were discovered and no protective measures such as unannounced management visits were provided. When further queried, NHA A reported he did not know if there were any patterns involved in the incidents i.e. the day of week in which they were identified, the time of day they were reported, if the same staff members worked prior to the discovery of the injuries, or if the residents who were injured were on the same staffing assignments.Review of the incidents in which residents suffered injuries of unknown origin between 9/10-11/2/25 revealed: 5 of the 6 incidents occurred on the memory care unit, all residents were severely cognitively impaired, 4 of the 6 incidents occurred on weekend shifts, 5 of the injuries were identified during morning cares.Review of an Abuse and Neglect Prohibition policy with a reference date of 11/6/24 revealed .D. The facility will monitor residents for.bruises/injuries of unknown origin.and trends that may constitute potential abuse and investigate such situations.5. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse, neglect.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cream on a burn? No.Using a greasy substance can seal in the heat and make the burn worse.The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME].

Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for Resident #100 with a reference date of 9/16/25 revealed Chief Complaint: Pt (patient) noted to have large bruise on right side of head. Unknow injury or fall. Also(sic) deformity noted to nose that RN says is not normal.Large, 10cm (centimeter) bruise and contusion on the right-side parietal area into the forehead.

There is a 3cm hematoma on the superior edge of the bruise without bogginess. There is a contusion at the bridge of the nose.there is a small nose bone fracture.Review of an Unusual Occurrences policy with a reference date of 6/10/21 revealed OVERVIEW: The facility will take the measures necessary to provide residents.with a safe and incident free environment. An incident is an unusual occurrence that happens within the facility that results in.resident harm. Examples of Unusual Occurrences include bruises, hematomas.3. If an unusual occurrence occurs a. immediately assess and treat the resident. b. notify the following individuals as soon as practicable after the incident occurs: i. Physician.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Interdisciplinary Team (IDT) was struggling to develop ideas.In an interview on 11/24/25 at 12:08pm, Certified Nursing Assistant (CNA) G reported she worked 3rd shift and had noted that Resident #101 needed to use the restroom very frequently. CNA G reported Resident #101 was aware of the need to urinate/have a bowel movement and became upset when he soiled himself. CNA G reported when Resident #101 soiled himself, he would attempt to clean himself up but could not remember to activate the call light and wait for help. CNA G confirmed she was not involved in developing interventions to reduce Resident #101's fall risk.In an interview on 11/24/25 at 11:50am, CNA F reported Resident #101 became stressed when he soiled himself and would attempt to clean himself up. CNA F reported Resident #101 at times appeared to have difficulty urinating when he tried to do so while on the toilet. CNA F also reported

she noticed Resident #101 consistently leaned to the left when sitting, standing and transferring.In an

interview on 11/24/25 at 8:24am, CNA AA reported nursing assistants were not involved in developing care interventions but added that he felt could provide information that would benefit the residents if asked.In an

interview on 11/24/25 at 10:21am, CNA JJ stated (Resident #101) does not like to be soiled. If he is wet, he takes off his brief and tries to walk to the bathroom.In an interview on 11/20/25 at 9:25am, CNA P confirmed Resident #101 displayed that it was important to him to be clean and dry because he expressed emotional distress when his brief was soiled.In an interview on 11/24/25 at 3:10pm RN BB reported Resident #101 frequently got up and tried to assist himself to the bathroom if his brief was soiled. RN BB reported sometimes the schedule for checking and changing Resident #101 ran late and he got up on his own.In an interview on 11/25/25 at 4:10pm, DON B reported the facility could not confirm Resident #101 was being assisted with toileting every 1-2 hours per his care plan because the staff had not been asked to document when they assisted him. DON B reported the IDT discussed changing the time Resident #101 received tamsulosin hydrochloride (medication used to treat urinary urgency by relaxing the muscles in the prostate and bladder), which was currently ordered to be given at 6:00pm, but had not done so. DON B reported the facility's pharmacist verified the medication could be given during the day if needed. DON B reported she had no knowledge of Resident #101 having urinary urgency or a longstanding history of losing his balance when he turned toward his right. DON B confirmed Resident #101 was still getting up several times a night to urinate. When further queried, DON B reported if Resident #101 has urinary urgency his care needs related to this issue should be included in his plan of care.Review of Physician Orders for Resident #101 with a reference date of 8/14/25 revealed Resident #101 was prescribed tamulosin HCI 4mg (milligrams) for benign prostatic hyperplasia (non-cancerous enlargement of the prostate causing difficulty starting urination .increased frequency and feeling of incomplete bladder emptying .).In an interview on 11/24/25 at 1:45pm, Nurse Practitioner (NP) NN reported she recently reviewed Resident #101's medications after he had multiple falls. NP NN she had not considered changing medication administration time of Resident #101's tamsulosin hydrochloride because she was unsure if the medication could only be given at night.In an interview on 11/24/25 at 1:17pm, Pharmacist QQ reported the peak time of effective for tamsulosin hydrochloride was 4-6 hours after it was given which would result in

the resident feeling a strong urge to urinate. Pharmacist QQ reported if a resident was at high risk for falling, the facility should consider giving the medication during the day.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Three Rivers

55378 Wilbur Rd Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Based on interview and record review, the facility failed to ensure 6 staff members (Certified Nursing Assistant (CNA) G, CNA TT, CNA Z, CNA G, CNA UU and Registered Nurse (RN) BB ) of 6 staff reviewed for behavioral competency, had the appropriate skills needed to provide care in a manner that supported each resident's psychosocial wellness, resulting in the potential for inappropriate staff to resident interactions, inability of staff to appropriately address residents in psychological distress, unmet care needs, and resident not maintaining or achieving highest practical psycho-social wellbeing. Findings include:In an

interview on 11/20/25 at 9:24am, CNA P reported she struggled to successfully care for several residents in

the memory care unit of the facility. CNA P reported working in memory care was her least favorite hall because she did not know how to care for the resident's without triggering their stress responses. CNA P stated I say I'm sorry to residents back there more than anywhere else in the building because they get so upset.In an interview on 11/20/25 at 1:58pm, CNA E reported she has worked in memory care for many years. CNA E reported some of the staff did not know how to approach residents in the memory care unit.

CNA E reported she regularly saw some staff members triggering residents' stress responses, the resident responding by flailing their arms, banging against things, and she wondered if that was why more residents were being found with injuries of unknown origin.In an interview on 11/21/25 at 8:29am, CNA Z reported several staff members did not seem to have the skills needed to avoid triggering psychological stress responses from the residents. CNA Z reported it was not uncommon for other CNA's to say they were unable to complete personal care for certain residents because the resident became too upset when approached.In an interview on 11/19/25 at 11:32pm, Registered Nurse (RN) GG reported some staff members did not know how to effectively care for residents who were prone to bouts of psychological distress. RN GG reported she witness staff approaching residents in a manner that led to unnecessary emotional distress. RN GG reported the staff members were not acting maliciously, they simple just did not understand how to approach the resident.In an interview on 11/24/25 at 4:10pm, Director of Nursing (DON) B reported staff were expected to have the skills they needed to successfully work in any area of the facility, at any time, including in the memory care unit.In an email on 11/25/25 at 9:17am, verification of staff competencies completed in the last 12 months was requested for 5 staff members, including CNA P, CNA TT and RN BB.In an interview on 11/25/25 at 10:16am, DON B reported it was determined that RN BB, CNA P, and CNA TT had not completed nursing competencies in the last 12 months, including a behavioral health competency. DON B reported CNA Z, CNA UU and RN BB had completed nursing competencies in

the last 12 months.Review of the competencies provided for CNA Z, CNA UU and RN BB, revealed the nursing competencies evaluated for these staff members were completed greater than 12 months ago.Review of staffing schedules revealed RN BB, CNA P, CNA G, CNA TT, CNA UU and CNA Z remained actively employed at the facility and provided care throughout the building.Review of a Facility Assessment with a reference date of 8/1/25 revealed INFORMATION ABOUT OUR RESIDENTS:.Severely impairment of cognition=43.5%, .CARE WE OFFER BASED ON OUR RESIDENT'S NEEDS: .care of someone with cognitive impairments, care of individuals with.trauma/PTSD (post-traumatic stress disorder), other psychiatric diagnoses.Training Program Evaluation:.We develop a curriculum and training plan on staff need and resident characteristics. The content at a minimum includes: .dementia management, special needs of residents, caring for resident who are cognitively impaired.cultural competency/trauma informed care.See F-F610 for additional information.

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