The Orchards at Three Rivers

In the surveyor’s words

From the most serious findings on record at The Orchards at Three Rivers, in the surveyor’s own words.

• Immediate jeopardy, isolatedF605Oct 30, 2025

  This 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. Findings include:Resident #102 (R102) was prescribed Haldol solution injection intramuscular (IM) daily as needed PRN and Olanzapine (Zyprexa) 5mg by mouth (PO) daily at night beginning 9/16/25. The Olanzapine was increased to 10 mg PO daily at night on 10/20/25. […]

• Actual harm, isolatedF689Nov 25, 2025

  This 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. […]

• Actual harm, isolatedF684Mar 21, 2024

  This 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. Findings include: According to the Minimum Data Set (MDS), [DATE], R102 was reported to have a memory problem with her cognitive skills for daily decision making severely cognitively impaired with a BIMS (Brief Interview Mental Status) score of ,d+[DATE]. […]

• Actual harm, isolatedF686Apr 14, 2021

  Based on observation, interview and record review, the facility failed to prevent the development of 2 facility acquired pressure ulcers and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of policy Prevention of Pressure Ulcers/Injuries revised July 2017, revealed, .Risk Assessment .e. Reposition resident as indicated on the care plan .Mobility/Repositioning .3. Reposition residents who are reclining and dependent on staff for repositioning .4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort . Review of an Face Sheet revealed Resident #38 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Mar 5, 2026

  Based 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. Findings include: Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. […]