The Orchards at Three Rivers: Seizure Medication Missed - MI
The inspection, conducted December 23, 2025, found that on the morning of December 22, the River Unit, which the facility's own Director of Nursing identified as requiring three CNAs due to the complexity of its residents' needs, had just one.
DON B told the inspector she had been notified of the situation that same morning, December 23, the day the inspector arrived.
The facility's stated minimum for any unit on day shift is two CNAs. The River Unit's higher threshold exists because its residents need more care, not less. On December 22, it had neither.
Administrator A and DON B said they were aware of the staffing concerns and were in the process of addressing them. Administrator A said the facility was monitoring staffing levels to ensure they met required state minimums. The inspection report does not indicate those minimums were being met.
The staffing finding was not the only concern inspectors documented. Residents had missed showers. Food complaints had accumulated. Administrator A said he fills out concern forms and takes them directly to the Dietary Manager and her supervisor, a process he described as his response to the problem. The kitchen had been outsourced to a contracted company on November 1, less than two months before the inspection.
Three separate issues, all of them known to leadership, all of them unresolved on the day inspectors walked in. The River Unit's residents spent part of December 22 with one person responsible for all of them.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
The Orchards at Three Rivers in Three Rivers, MI was cited for violations during a health inspection on December 23, 2025.
DON B told the inspector she had been notified of the situation that same morning, December 23, the day the inspector arrived.
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.