The Orchards at Three Rivers: Consent Violations - MI
The resident, identified in inspection records only as Resident 106, had been prescribed Olanzapine, Duloxetine, Mirtazapine, and Quetiapine Fumarate. All four are psychotropic medications, drugs that act on the brain and central nervous system and carry significant side effect profiles. All four were being administered without the written consent documentation the facility's own leadership acknowledged was required.
Inspectors submitted a written request on December 22, 2025 asking the Nursing Home Administrator, identified in records as NHA A, to provide any and all consent forms on file for those four medications.
That afternoon, NHA A said the facility had nothing. No written consent forms for any of the four drugs. The only documentation the facility could produce was a record of verbal consent from a care conference held with Resident 106's spouse sometime in December 2025.
Two minutes later, the Director of Nursing, identified as DON B, told inspectors that any psychotropic medication administered to a resident should have a consent form on file.
That was the state of the record: the administrator confirming the forms did not exist, and the nursing director confirming they should.
The inspection, which was complaint-driven, was completed December 23, 2025. CMS classified the violation under F0552, which covers residents' rights to be informed and to make decisions, including decisions about their own medical treatment. The harm level was assessed as minimal harm or potential for actual harm, and the violation was found to affect a small number of residents.
The consent gap matters beyond paperwork. Psychotropic medications are among the most scrutinized drugs in nursing home care precisely because of their effects on cognition, behavior, and physical function. Olanzapine and Quetiapine are antipsychotics. Duloxetine is an antidepressant and nerve pain medication. Mirtazapine is an antidepressant also used to stimulate appetite. Each carries its own risk profile. Each, according to the facility's own Director of Nursing, required documented consent before administration.
The verbal consent note from a December care conference with the resident's spouse represents the only evidence that anyone with authority over Resident 106's care was informed about the medication regimen at all. Whether that conversation covered all four drugs, whether it happened before or after the medications were started, and how long the resident had been receiving the drugs without any consent documentation in place, the inspection report does not say.
What it does say is that when the facility was asked to show its work, it could not.
The Orchards at Three Rivers is located at 55378 Wilbur Rd in Three Rivers, Michigan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Three Rivers from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
The Orchards at Three Rivers in Three Rivers, MI was cited for violations during a health inspection on December 23, 2025.
The resident, identified in inspection records only as Resident 106, had been prescribed Olanzapine, Duloxetine, Mirtazapine, and Quetiapine Fumarate.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.