The Orchards at Three Rivers

Inspectors wroteBased on observation, interview, and record review, the facility failed to A.) operationalize an effective infection control program B.) have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP) C.) follow transmission-based precaution (TBP) and enhanced barrier precautions (EBP) guidelines for 4 (Resident #7, #54, #35, and #87) residents resulting in the potential for the development and transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an orderly and clean living environment was maintained for 8 (Residents #30, 74, 87, 50, 70, 40, 41, and 2) of 8 residents reviewed for environment resulting in a dirty living environment and being dissatisfied with the level of cleanliness and order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% in 2 of 4 residents (Resident #33 and #54) reviewed for medication administration, when wrong dosages of medications were administered, and medications that were not to be crushed were administered crushed, resulting in the potential for adverse medication side effects.

Inspectors wroteBased on interview and record review, the facility failed to designate an Infection Preventionist (IP) that had adequate time to perform infection prevention responsibilities and oversee the infection control program. This deficient practice resulted in the potential for the spread of infection, cross-contamination, and disease transmission for all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility to failed to ensure call lights were within reach for 1 (Resident #7) of18 residents reviewed for accommodation of needs, resulting in the potential for unmet care needs.

Inspectors wroteThis citation pertains to Intake # 2749154. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 1 resident (Resident #41) reviewed for notification of changes, resulting in the family/responsible party being unaware of a newly identified urinary tract infection and initiation of antibiotic treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure the Notice of Transfer and Bed Hold documentation was provided in writing prior to transfer from facility for 1 (Resident #3) of 2 residents reviewed for hospitalization, resulting in the potential for the resident or resident representative to be uninformed of rights related to transfer to hospital and bed hold policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration in 1 of 4 residents (Resident #33) reviewed for medication administration, resulting in medications being crushed against pharmacy recommendations and the potential for adverse medication side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and implement pressure ulcer preventative care, consistent with professional standards of practice, for 1 (Resident #7) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the potential for the development of an pressure ulcer and potential for worsening of pressure wounds, and overall deterioration in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (delivery of nutrients directly into the gastrointestinal tract through a feeding tube) in 1 (Resident #7) of 1 resident reviewed for tube feeding, resulting in the potential for aspiration pneumonia.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain oxygen equipment in a sanitary manner and follow physician's oxygen orders for 1 (Resident #87) of 1 resident reviewed for respiratory care resulting in the potential for excessive oxygen levels and/or an infection.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records in 2 of 18 residents (Resident #61 & #7) reviewed for accuracy of medical records, resulting in inaccurate code status information within the electronic health record and missing documentation in the treatment record with the potential for advanced directive/code status preferences to not be honored and deterioration in resident status.

Inspectors wroteBased on interview and record review, the facility failed to ensure they educated, offered and administered COVID-19 vaccines or maintained valid declination in the medical record for 1(Resident #87) of 5 residents reviewed for Covid-19 immunizations resulting in the increased likelihood of severe infection and complications/death related to COVID-19.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to intake 2689916. Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and failed to implement effective corrective interventions for known issues involving staffing and meal service, with the potential to impact all residents who reside at the facility, resulting in insufficient staff to meet resident needs and poor food quality.

Inspectors wroteThis citation pertains to Intake # 2670974, 2689916, & 2646054. Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment in 3 of 5 residents (Resident #102, #103, & #108) reviewed for a safe/clean environment, resulting in refusal of care due to uncomfortable water temperatures and dissatisfaction with the living conditions.

Inspectors wroteThis citation pertains to Intake # 2670974 & 2689916. Based on interview, and record review, the facility failed to ensure showers/baths were provided per resident preference and plan of care in in 4 of 7 residents (Resident #101, #102, #103, & #113) reviewed for showers/bathing, resulting in dissatisfaction with the care provided and the potential for discomfort and feelings of impaired self-worth.

Inspectors wroteThis citation pertains to Intake # 2670974, 2689916, 2646054, 2639254, & 2693899. Based on interview, and record review, the facility failed to ensure sufficient staffing to meet resident needs in 4 of 6 residents (Resident #102, #103, #108, & #109) reviewed for sufficient staffing and timely response to resident needs, resulting in long call light wait times, missed showers, and the potential for unmet needs.

Inspectors wroteThis citation pertains to Intake # 2689916. Based on observation, interview, and record review, the facility failed to follow the menu and serve food items from the menu as scheduled, post the current menu for residents to review, and update the menu with changes when they occurred, in 1 of 8 residents (Resident #103) reviewed for food, with the potential to affect all residents who receive meals from the kitchen, resulting in frustration with the food service process and the potential for decreased intake.

Inspectors wroteThis citation pertains to Intake # 2670974, 2689916, 2671774, 2667436, 2646054, 2639254, 2599079, 2693899, & 2693872. Based on observation, interview, and record review, the facility failed to provide adequate portions of palatable food, served at an appetizing temperature in 8 of 9 residents (Resident #102, #103, #105, #108, #109, #110, #111, & #113) reviewed for food quality, resulting in dissatisfaction with the meals served, frustration with the food service process, and the potential for decreased meal intake and weight loss.

Inspectors wroteThis citation pertains to Intake #2690782Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for 1 (Resident #106) of 3 residents reviewed for notification of change resulting in lack of communication and/or education to the resident/resident representative for initiation and/or dose changes of psychotropic medications.

Inspectors wroteThis citation pertains to Intake # 2677000 & 2693899. Based on interview, and record review, the facility failed to ensure ordered medications were administered timely per physician orders in 2 of 8 residents (Resident #107 & #114) reviewed for quality of care, resulting in a delay of care, and the potential for worsened infection, increased seizure activity, and impaired health status.

Inspectors wroteThis citation pertains to intakes #2658740, #2635653 and #2671515Based on observation, interview, and record review, the facility failed to implement interventions to reduce hazards for 5 residents (Resident #103, Resident #106, Resident #107, Resident #108, and Resident #101) of 5 residents reviewed for accidents, resulting in: 1. Resident #103 suffering a second degree burn when she was provided hot coffee without being assessed for her ability to manage a hot beverage and Resident #106, #107 and #108 being given a hot beverage without being assessed for their ability to safety handle it. 2. Resident #101 experiencing multiple falls due to a lack of monitoring for effectiveness of interventions and modification of interventions.

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to intakes #2663418, # 2648487, 2648458, 2645961, and #2671459Based on interview and record review, the facility failed to thoroughly investigate an incident of potential mistreatment for 4 (Resident #100, Resident #102, Resident #104, and Resident #109) of 5 residents reviewed for abuse resulting in the potential for mistreatment to go unrecognized and resolved.

Inspectors wroteBased 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.

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to intake #2671515Based on interview and record review the facility failed to provide appropriate first aid care for a burn for 1 (Resident #103) of 3 residents reviewed for professional standards, resulting in Resident #103 (who suffered a second-degree burn) receiving inappropriate treatment and a potential for worsening of the injury because of the care provided.

Inspectors wroteThis citation pertains to intake #2663418Based on interview and record review the facility failed to promptly recognize and assess 1 resident (Resident #100) of 3 reviewed for quality of care, resulting in Resident #100, who had new symptoms of unknown head trauma, not being properly assessed for 5 days, and a potential for care needs to go unmet.

Inspectors wroteThis citation pertains to intake number: 2640123Based on observation, interview, and record review, the facility failed to prevent the use of psychotropic medications without adequate indication for use and without resident monitoring in one (R102) of two residents reviewed for psychotropic medications, resulting in an immediate jeopardy when beginning on 9/16/25, R102 was prescribed psychotropic medications, who then experienced increased sedation, weight loss, and decreased ability to communicate.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program identified and corrected quality deficiencies, resulting in decreased quality of care.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within reach for 1 of 2 residents (R102) reviewed for accommodation of needs, resulting in the potential for residents to not meet their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide resident centered activities designed to support leisure needs for 1 (Resident #102) of 3 residents reviewed for activities, resulting in the potential for decreased physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake number: 2640123Based on observation, interview, and record review the facility failed to develop and implement person centered dementia care interventions to address wandering, disorientation, and frustration for 1 (Resident #102) of 3 residents reviewed for dementia care, resulting in Resident #102 experiencing ongoing wandering, emotional frustration, and stress.

Inspectors wroteThis citation pertains to intake number: 2640123Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record in 1 of 3 residents (Resident #102) reviewed for comprehensive/accurate medical records, resulting in inaccurate documentation and the potential for unmet needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that staff was adequately trained and evaluated for competencies specifically related to administration of Peritoneal Dialysis (PD) (a procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) in 5 (Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11) of 5 residents reviewed for PD, resulting in the potential for unsafe administration of PD, unrecognized complications, increased risk for infection and adverse reactions.

Inspectors wroteBased on interview and record review the facility failed to ensure 1). pre and post dialysis treatment assessments were completed; 2). administration of peritoneal dialysis (PD)(a procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) was administered by qualified trained staff; 3). ongoing assessments and/or monitoring were completed during the administration of peritoneal dialysis; 4). ongoing communication between the facility and the dialysis facility (Name Omitted) was documented; and 5). [...]

Inspectors wroteBased on interview and record review, the facility failed to administer its policies and procedures in a manner that displayed effective and efficient use of resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11) of 5 residents reviewed. This deficient practice resulted in 8 staff members administering treatments to Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11, they were neither trained nor qualified to administer.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1). implement gait belt use for safety during ambulation (walking) of one resident (Resident #5) and 2). ensure safe transport of a resident in a wheelchair with footrests in place in 1 (Resident #6) of 3 residents reviewed for safety, resulting in the potential for an accident, and/or an injury to occur during ambulation and transport.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store narcotic medications in a secure manner resulting in the potential for residents, visitors, and/or staff to access the medication in the facility with a current census of 82 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper infection control protocols and practices as evidenced by: 1). The use of personal protective equipment (PPE) during personal care and transfers for 2 (Resident #2 and Resident #7) of 2 residents requiring enhanced barrier precautions, 2. Sanitize resident shared equipment during uses, resulting in increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility.

Inspectors wroteThis citation pertains to intake MI00151744 Based on observation, interview, and record review the facility failed to ensure the dietary manager had adequate competencies and skill set to carry out the functions of the food and nutrition service resulting in potential for unmet nutrition and hydration needs for all residents who rely on food and hydration from the facility kitchen.

Inspectors wroteThis citation pertains to intake MI00151744 Based on observation, interview, and record review the facility failed to follow menus resulting in the potential for inadequate nutritional value, unequal substituted nutritional value, and unmet nutritional needs. This deficient practice has the potential to affect all residents who consume food from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop person centered care plans for 1 (Resident #104) of 9 residents reviewed for person centered care plans resulting in an inaccurate reflection of the resident's current care needs and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise person centered care plan for 1 (Resident #106) for 9 residents reviewed for person centered care plans resulting in an inaccurate and incomplete description of resident current care needs and the potential for unmet care needs.

Inspectors wroteThis citation pertains to intake MI00148764 Based on interview and record review the facility failed to provide activities of daily living (ADL) to dependent residents, specifically showers to 2 (Resident #101 and Resident #102) of 3 residents reviewed for activities of daily living and showers, resulting in showers not being given as scheduled.

Inspectors wroteThis citation pertains to intakes MI00150708, MI00150714, and MI00151319. Based on observation, interview and record review the facility failed to ensure adequate supervision for safety for 3 (Resident #104, Resident #105, and Resident #106) of 3 residents reviewed for supervision resulting in Resident #105 hitting Resident #104, Resident #105 spitting on Resident #104 and Resident #106 eloping (exit without supervision) from the building.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the use of personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for 2 (Resident #104 and Resident #106) of 4 residents reviewed for enhanced barrier precautions personal protective equipment use, resulting in the potential for introduction of infection, disease transmission, and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the potential to affect all 73 residents.

Inspectors wroteBased on observation and interview the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. This deficient practice has the potential to affect all 73 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide annual required abuse prevention education for all employees. This has the potential to affect all 73 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury among residents in the following areas.

Inspectors wroteBased on interview and record review the facility failed to 1.) provide proper documentation of notice of transfers to 2 (Residents #72, and #40) of 3 residents who were transferred from the facility and 2.) provide resident transfer notifications to the local ombudsman.

Inspectors wroteResident #35 Review of an admission Record revealed Resident #35 had pertinent diagnoses which included: Alzheimer's disease, dementia, and contracture (condition that causes a joint to become very stiff and prevents normal movement) of the right hand. Review of Physician Orders for Resident #35 revealed monitor skin integrity to RUE (right upper extremity) (R Hand) related to splint use, started on 6/12/2023. Review of Care Plan for Resident #35 revealed soft hand splint to right hand apply every morning and remove at HS (bedtime). During an observation on 11/14/24 at 3:43 PM., Resident #35 was lying in bed and did not have a soft splint on her right arm. Review of Physician Order for Resident #35 revealed remove splint Q (every) HS at bedtime for contracture management note to be discontinued on 9/9/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain nebulizer equipment for 1 (Resident #2) of 1 resident reviewed for respiratory care resulting in the potential for inconsistent equipment exchange, irregular cleaning, and respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 consents or declinations were obtained for 2 residents (Resident #44, Resident #37) of 5 reviewed for immunizations resulting in residents/family members being unaware of the vaccination and the risks/benefits of having it completed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of training for behavioral health care and services for 128 staff reviewed for behavioral health care and dementia training. This deficient practice had the potential to result in unmet behavioral health care needs and services for residents.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an elopement and submit an investigation report to the State Agency within 5 days, for one resident (Resident #100) of three residents reviewed for abuse, from a total sample of 4 Residents, resulting in an elopement being unidentified or properly investigated, and the potential for continued elopements to go unreported and thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility failed to develop a person centered care plan for one resident (Resident #100) of three residents reviewed for elopement, resulting in the resident exiting the building unsupervised, and a potential for the resident to experience more than minimal harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment that was free from accident hazards for two residents (Resident #100 and Resident #104) of four residents reviewed for accidents. This deficient practiced resulted in an elopement for Resident #100 and the potential for more than minimal harm, and Resident #104 enduring a head laceration when he fell from mechanical lift that had not been properly maintained.

Inspectors wroteThis citation pertains to intakes MI00142592 and MI00142727. Based on interview and record review, the facility failed to assess an acute change of condition in 1 of 4 residents (R102) and failed to provide appropriate skin care for open wounds in 1 of 4 residents (R103) reviewed for quality of care, resulting in a delay in assessment, treatment and subsequent hospitalization for for dehydration and hypernatremia (elevated sodium) for R102 and the potential for infection for R103.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately assist a resident with Activities of Daily Living (ADL) care for 1 (Resident #35) 3 residents reviewed for ADL care, resulting in Resident #35 having unshaven facial hair and the potential for feelings of embarrassment and self-consciousness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise 1 (Resident #42) of 5 residents reviewed for accidents/hazards resulting in Resident #42 consuming a non-food item during her meal and the potential for choking.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that supplemental oxygen was continuously supplied to 1 resident (Resident #31) of 1 reviewed for continuous oxygen use resulting in fear and anxiety, shortness of breath, and hypoxia (low oxygen levels in the blood) which can lead to confusion, disorientation, decreased consciousness, and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1.) perform proper hand hygiene during catheter care in 1 resident (Resident #38) of 1 reviewed for catheter care and 2.) ensure sanitary conditions for privacy curtains in resident's rooms, resulting in the potential for the introduction of infection, cross-contamination, and disease transmission.