The Orchards At Three Rivers

F 0552

medications Resident #106 was on.

Level of Harm - Minimal harm or potential for actual harm

In electronic correspondence on 12/22/25 at 11:07 AM, Nursing Home Administrator (NHA) A was requested to provide any and all medication consent forms available for Resident #106 for Olanzapine, Duloxetine, Mirtazapine, and Seroquel (Quetiapine Fumarate).

Residents Affected - Few

In an interview on 12/22/25 at 3:26 PM, NHA A reported the facility could not find any consents for Resident #106 for the psychotropic medications Duloxetine HCl, Mirtazapine, Olanzapine, Quetiapine Fumarate he was prescribed. NHA A reported the facility had the verbal consent documentation from the care conference held with Resident #106's spouse in December 2025 but that was all.

In an interview on 12/22/25 at 3:28 PM, Director of Nursing (DON) B reported any psychotropic medication that is administered should have a consent.

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

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Review of an admission Note for Resident #108, dated 10/16/25 at 7:59 PM, revealed .patient arrived to facility .assisted from car to wheelchair and into room .alert and oriented x 3 .

In an interview on 12/16/25 at 3:28 PM, Resident #108 reported concerns with the physical environment while at the facility. Resident #108 reported significant amounts of chipped paint on the walls of his room.

Resident #108 reported his room was dirty, and there was a dirty pillow on the floor under his bed when he first admitted .

In an observation on 12/17/25 at 1:54 PM, noted the door was open to the Meadow Lane Spa room.

Observed the left side of the door frame (near the base) was rusted out with visible pieces of rust and debris on the floor. Observed chipped tile along the wall. Noted a foul odor coming from the spa room and observed a three-compartment hopper which contained bags of trash.

In an observation on 12/23/25 at 8:18 AM, noted a flagpole in the front parking area near the main entrance to the facility. Noted the American flag was in poor condition, visibly faded with multiple rips/tears in the fabric of the flag. Observed several discarded rubber gloves laying on the driveway.

On 12/22/25 at 10:28 AM, an interview with LPN X found that the 100-hall shower room has shown some hot water issues within the last couple months.

On 12/22/25, at 10:53 AM, an interview with Maintenance Director (MD) RR found that there should be enough hot water to maintain shower temperatures. When asked why the complaints regarding hot water are being heard, MD RR stated that he has trained staff that they need to let the water warm up for one minute.

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

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

next one .Resident #113Review of an admission Record revealed Resident #113 was a male, with pertinent diagnoses which included Huntington's disease (a brain disorder causing nerve cells to break down, leading to uncontrolled movements, cognitive decline, and psychiatric issues), dysphagia (difficulty swallowing), anxiety, depression, high blood pressure, muscle weakness, difficulty walking, and need for assistance with personal care.Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 11/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, indicating he had moderate cognitive impairment.Review of a current Care Plan for Resident #113 revealed the focus .(Resident #113) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Huntington's, weakness, unstable gait . revised 8/28/25, with interventions which included .BATHING/SHOWERING: The resident requires max assistance by 1 staff with bathing/showering . revised 12/2/25.In an interview on 12/17/25 at 4:07 PM, Family Member KK reported concerns with missed showers for Resident #113.Reviewed of the unit Bath Schedule revealed Resident #113 was scheduled to receive baths/showers on Tuesdays and Saturdays, on first shift.Reviewed provided shower documentation for Resident #113 from 11/15/25 to 12/22/25. Noted missed showers (no documentation) on Saturday 11/22/25, Saturday 11/29/25, Tuesday 12/2/25, and Saturday 12/13/25.In an

interview on 12/22/25 at 11:35 AM, Unit Manager Q reported each unit has a schedule for resident showers. Unit Manager Q reported staff follow the shower schedule, and make changes as needed based

on preference. Unit Manager Q reported for each shower, CNAs complete a shower sheet. Unit Manager Q reported the primary method of shower documentation was shower sheets. Unit Manager Q stated .We were doing an order in the computer for the nurses to sign off. We are slowly going away from that . Unit Manager Q reported shower/bath refusals would still be documented on a shower sheet, and the nurse would be notified.

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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

.Review of an Order Summary Report for Resident #114 revealed the physician order .Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth two times a day for seizures . with a start date of 12/12/25.Review of the December 2025 Medication Administration Record (MAR) for Resident #114 revealed the physician order .Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth two times a day for seizures . had missed doses (medication was documented as not given) on 12/12/25 at 6:00 PM, 12/13/25 at 9:00 AM and 6:00 PM, 12/14/25 at 9:00 AM and 6:00 PM, 12/15/25 at 9:00 AM and 6:00 PM, 12/16/25 at 9:00 AM and 6:00 PM, and 12/17/25 at 9:00 AM (with documentation to see the progress notes). Noted Resident #114 missed a total of 10 scheduled doses of his seizure medication.Review of an Orders - Administration Note for Resident #114, dated 12/12/25 at 5:59 PM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .awaiting supply on order .Review of an Orders - Administration Note for Resident #114, dated 12/13/25 at 10:47 AM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .on order. (Physician) aware. No Seizure activity noted .Review of an Orders - Administration Note for Resident #114, dated 12/13/25 at 5:38 PM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .ON ORDER .(Physician) aware. No seizure activity noted .Review of an Orders - Administration Note for Resident #114, dated 12/14/25 at 9:44 AM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .On order .(Physician) aware .no seizure activity noted .Review of an Orders Administration Note for Resident #114, dated 12/14/25 at 5:36 PM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .(Physician) aware. No seizure activity noted .Review of an Orders - Administration Note for Resident #114, dated 12/15/25 at 9:36 AM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .on order .(prescription) to be signed faxed to (Physician) .2nd attempt. No seizure activity noted .Review of an Orders - Administration Note for Resident #114, dated 12/15/25 at 5:19 PM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .on order pending (Physician) to call prescription. No (signs/symptoms of) seizure activity noted .Review of an Orders - Administration Note for Resident #114, dated 12/16/25 at 9:01 AM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .On order .no (signs/symptoms of) seizure activity noted .Review of an Orders - Administration Note for Resident #114, dated 12/16/25 at 6:32 PM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .Med (medication) on order .Review of

an Orders - Administration Note for Resident #114, dated 12/17/25 at 10:05 AM, revealed Lacosamide Oral Tablet 100 MG Give 1 tablet by mouth two times a day for seizures .(prescription) faxed to (physician) again .no (signs/symptoms) of seizure activity noted .(Unit Manager Q) and administrator aware .In an interview

on 12/23/25 at 10:15 AM, RN C reported Resident #114 admitted to the facility on a Friday (12/12/25), and when she cared for him on Saturday, she did not see a signed prescription for his Lacosamide. RN C reported she sent a request to the physician group for a signed prescription but never received a response over the weekend. RN C reported she sent the request again on Monday (12/15/25), and the physician signed it, however the pharmacy did not approve of the type of signature used. RN C reported Unit Manager Q took over the responsibility to obtain a signed prescription for Resident #114's Lacosamide on Monday (12/15/25). RN C reported Resident #114 did not receive a dose of his Lacosamide until Wednesday (12/17/25) afternoon.In an interview on 12/23/25 at 10:22 AM, Unit Manager Q reported she scanned and sent the request for Resident #114's signed Lacosamide prescription on Monday 12/15/25.

Unit Manager Q reported the physician did not send the signed prescription until the next day (Tuesday 12/16/25) but she (Unit Manager Q) was off that day.

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

.Review of the policy/procedure Staffing and Posting, revised 1/2025, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Review of the policy/procedure Call Light, dated 7/2018, revealed .Call lights should be answered by available staff as promptly as possible . When answering the call light, the staff member should inquire as to the need, and if possible, meet that need as soon as practicable .

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

for Week 1 through Week 3. No dates on menu to indicate if Week 4 was the current week for the menu cycle.

In an observation on 12/22/25 at 11:05 AM, noted two pages of menus (double-sided copies) posted on the wall of the main dining room. The menu visible on the outside was for Week 4. Note the pages were stapled together and would require a person to flip through the remaining pages to view the menus for Week 1 through Week 3. No dates on menu to indicate if Week 4 was the current week for the menu cycle.

On 12/22/25 at 9:31 AM, an interview with Assistant Manager of Dietary Services (AMDS) PP, regarding menu inconsistency, found that some newer staff have had issues following which week of the menu the facility has been on, and instead have made meals from different weeks. This not only doesn't follow the menu but can change what the kitchen has available to make for the meals on the menu that week.

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

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0804

On 12/22/25 at 12:52 PM, the meal cart was delivered to the River unit and trays were being passed.

Level of Harm - Minimal harm or potential for actual harm

On 12/22/25 at 1:06 PM, all trays on the meal cart were passed and the test tray was back in the conference room with the following temperatures noted using a rapid read thermometer: Chicken tenders 104F, Grean Beans 113F, and the stuffing was 128F.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0812

used in accordance with manufacturer's instructions.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

.In an interview on 12/23/25 at 1:26 PM, Administrator A and DON B reported they were aware of concerns regarding missed showers and were in the process of addressing the issue. Administrator A reported he was aware of the expressed food concerns and reported he fills out concern forms and takes the concerns directly to Dietary Manager VV and her supervisor. Administrator A reported the kitchen (dietary services) was outsourced (contracted with a separate company) on 11/1/25. Administrator A and DON B reported

they were aware of the staffing concerns and in the process of addressing the issue. Administrator A reported they are monitoring staffing levels to ensure that they are meeting the required state minimums.

Administrator A and DON B reported the lowest staffing they would deem acceptable for day shift would be two CNAs on each unit. DON B reported they did a review of their staffing and acuity and determined the River Unit should have three CNAs, as it has a higher acuity of residents. Inquired about the staffing levels for the River Unit yesterday (12/22/25) on day shift, as there was only one CNA on the unit for a period of time, and DON B reported she was notified of that situation today (12/23/25).

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Facility ID:

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